Faculty Bibliography

Children aged 1-5 years enrolled in Medicaid are at increased risk for having elevated blood lead levels (BLLs). According to estimates from the National Health and Nutrition Examination Survey (NHANES) (1991-1994), Medicaid enrollees accounted for 83% of U.S. children aged 1-5 years who had BLLs > or = 20 microg/dL. Despite longstanding requirements for blood lead screening in the Medicaid program, an estimated 81% of young children enrolled in Medicaid had not been screened with a blood lead test. As a result, most children with elevated BLLs are not identified and, therefore, do not receive appropriate treatment or environmental intervention. To ensure delivery of blood lead screening and follow-up services for young children enrolled in Medicaid, the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) recommends specific steps for health-care providers and states. Health-care providers and health plans should provide blood lead screening and diagnostic and treatment services for children enrolled in Medicaid, consistent with federal law, and refer children with elevated BLLs for environmental and public health follow-up services. States should change policies and programs to ensure that young children enrolled in Medicaid receive the screening and follow-up services to which they are legally entitled. Toward this end, states should a) ensure that their own Medicaid policies comply with federal requirements, b) support health-care providers and health plans in delivering screening and follow-up services, and c) ensure that children identified with elevated BLLs receive essential, yet often overlooked, environmental follow-up care. States should also monitor screening performance and BLLs among young children enrolled in Medicaid. Finally, states should implement innovative blood lead screening strategies in areas where conventional screening services have been insufficient. This report provides recommendations for improved screening strategies and relevant background information for health-care providers, state health officials, and other persons interested in improving the delivery of lead-related services to young children served by Medicaid

The Child Health Supplement to the 1988 National Health Interview Survey was used to examine parent-reported current asthma among a nationally representative sample of 17,110 children zero to 17 yr of age. Numerous demographic variables were analyzed for independent associations with asthma using modified stepwise logistic regression, with models including specific combinations of risk factors. Black children had higher rates of asthma than did white children in unadjusted analyses, but after controlling for multiple factors, black race was not a significant correlate of asthma (adjusted odds ratio = 0.87, 95% CI = 0.63 to 1.21). Compared with nonurban white children, urban children, both black and white, were at significantly increased risk of asthma: urban and black (adjusted OR = 1.45, 95% CI = 1.14 to 1.86), urban and white (adjusted OR = 1.22, 95% CI = 1.01 to 1.48), whereas nonurban black children were not: nonurban and black (adjusted OR = 1.15, 95% CI = 0.83 to 1.61). Similarly, compared with nonurban, nonpoor children, urban and poor (adjusted OR = 1.44, 95% CI = 1.05 to 1.95), urban and nonpoor (adjusted OR = 1.22, 95% CI = 1.004 to 1.48), urban children, both poor and nonpoor, were at significantly increased risk of asthma, whereas nonurban poor children were not: nonurban and poor (adjusted OR = 1.03, 95% CI = 0.72 to 1.48). These results suggest that the higher prevalence of asthma among black children is not due to race or to low income per se, and that all children living in an urban setting are at increased risk for asthma

OBJECTIVE: To compare the effect of formula company-produced materials about infant feeding to breast-feeding promotion materials without formula advertising on breast-feeding initiation and duration. METHODS: Five hundred forty-seven pregnant women were randomized to receive either formula company (commercial; n = 277) or specially designed (research; n = 270) educational packs about infant feeding at their first prenatal visit. Feeding method was determined at delivery. Breast-feeding duration of the 294 women who chose to breast-feed was ascertained at 2, 6, 12, and 24 weeks. Survival analyses were used to evaluate continuous outcomes, and chi2 and logistic regression analyses were used to evaluate discrete outcomes. RESULTS: Breast-feeding initiation (relative risk [RR] 0.93, 95% confidence interval [CI] 0.61, 1.43) and duration after 2 weeks (hazard ratio 1.19, 95% CI 0.86, 1.64) were not affected. Women in the commercial group were more likely to cease breast-feeding before hospital discharge (RR 5.80, 95% CI 1.25, 54.01) and before 2 weeks (adjusted odds ratio [OR] 1.91, 95% CI 1.02, 3.55). In subgroup analyses, women with uncertain goals for breast-feeding or goals of 12 weeks or less experienced shortened exclusive (hazard ratio 1.53, 95% CI 1.06, 2.21), full (hazard ratio 1.70, 95% CI 1.18, 2.48), and overall (hazard ratio 1.75, 95% CI 1.16, 2.64) breast-feeding duration when exposed to the commercial intervention. CONCLUSION: Although breast-feeding initiation and long-term duration were not affected, exposure to formula promotion materials increased significantly breast-feeding cessation in the first 2 weeks. Additionally, among women with uncertain goals or breast-feeding goals of 12 weeks or less, exclusive, full, and overall breast-feeding duration were shortened. Educational materials about infant feeding should support unequivocally breast-feeding as optimal nutrition for infants; formula promotion products should be eliminated from prenatal settings

OBJECTIVE: To compare the health, behavior and school problems, and use of medical, mental health, and special education services of privately insured, middle class black and white children in the United States. DESIGN/METHODS: Analyses of the Child Health Supplement to the 1988 National Health Interview Survey, with a nationally representative sample of 17 110 children age 0-17 years. RESULTS: Privately insured middle class black children had fewer chronic health conditions, but were less likely to be reported to be in excellent health (46.2% vs 57.3%) and more likely to have had asthma (8.5% vs 5.8%) or to have been of low birth weight (10.7% vs 5.6%). There were no differences in rates of having a usual source of routine care (92.2% vs 93.8%) or of being up to date with well-child care (79.3% vs 78.2%), but black children made fewer physician visits, were less likely to use physicians' offices, were more likely to lack continuity of care, and were twice as likely to use emergency departments. These differences in use of medical services persisted in multivariate analyses and analyses restricted to more affluent children. Despite similar rates of behavior problems, black children were more likely to repeat a grade (20.0% vs 12.3%) and to have been suspended from school (11.3% vs 5.0%). Although significantly fewer black middle class children received mental health or special education services in bivariate analyses, no differences in receipt of these services were noted in multivariate analyses. All differences reported were significant. CONCLUSIONS: Among middle class children in the United States, black and white children have similar rates of health and behavior problems, but black children experience substantially increased rates of asthma, low birth weight, and school difficulties. Although not differing in the receipt of mental health or special education services, middle class black children, even in the presence of private health insurance, have markedly different sources and patterns of use of medical services

OBJECTIVE: To compare baseline characteristics, service provision, and child placement for infants exposed to cocaine in utero based on postnatal screening results. METHODS: We studied a retrospective cohort of 40 consecutive drug-exposed, but seemingly healthy term infants who underwent urine drug screening in the newborn nursery of a community hospital. Using clinical and service agency data, two cocaine-exposed cohorts were compared (a) screen-positive at birth (n = 22) versus (b) screen-negative at birth (n = 18). RESULTS: Both cocaine-exposed groups had similar infant birth weights, levels of paternal involvement, maternal ages, gravidity, parity, and lengths of gestation. Mothers in both groups had similar histories of prostitution, poor home environment, drug use, and prenatal drug rehabilitation. Mothers of screen-positive infants were more likely than mothers of screen-negative infants to have other children in foster care (27% vs. 6%, p = .07), to have experienced previous interventions by child protective services (CPS) (55% vs. 17%, p < .01), to have had no prenatal care (32% vs. 6%, p = .09), and fewer prenatal visits (4.7 vs. 8.6, p = .02). Compared to screen-negative infants, more screen-positive infants were referred to a high-risk infant tracking program (91% vs. 6%), referred to CPS (100% vs. 33%), placed outside the mother's home (50% vs. 22%), and had their mothers referred to drug rehabilitation (36% vs. 11%), (p < .01 for each). By 1 year of age, support services differed little between exposed cohorts. However, 6 of 22 screen-positive infants were in foster care and 3 were placed for adoption, while only 1 of the 18 screen-negative infants was in foster care and only 1 had been placed for adoption. There were no services available in this community to provide coordinated or comprehensive services or drug treatment specific to the needs of drug using mothers and drug exposed infants. CONCLUSIONS: Despite similarities between cocaine-exposed infants cared for in a normal newborn setting (with and without positive urine drug screens at birth), differences in referral services were noted. More striking than these differences was that services for families with drug-exposed infants are inadequate to even meet the needs of those families in our setting deemed to be at highest risk. Neonatal drug screening needs to be paired with effective services